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Altered Mental Status in a Patient With Substance Use Disorder
Case Study
The bedside nurse initiated a rapid response event for a patient because of acute onset of unresponsiveness. The registered nurse (RN) was doing his morning medication rounds and found the patient unresponsive. The patient was also taking infrequent shallow breaths. On arrival of the rapid response team, the bedside RN informed that the patient is a 23-year-old male with a history of heroin abuse and anxiety, admitted two days ago for suspected infective endocarditis. He was started on antibiotics via a peripherally inserted central catheter (PICC) line for tricuspid endocarditis. The only other medication he was receiving was sertraline. While performing a fingerstick glucose check, the nursing staff found a needle and syringe by the patient’s side. Additionally, two small plastic bags with a white powder residue were found on the floor.
Vital Signs
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Temperature: 98.9 °F, axillary.
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Blood Pressure: 118/60 mmHg
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Heart Rate: 74 beats per min – normal sinus rhythm on telemetry
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Respiratory Rate: 6 breaths per min
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Pulse Oximetry: 84% on room air
Physical Examination
A quick exam revealed a young adult male with a Glasgow Coma Scale (GCS) score of ten (E3 V3 M4) with pinpoint pupils. He was initially noted to have cyanosis of his lips and agonal breathing. His heart rate was regular without an appreciable murmur. His extremities were warm with good distal pulses.
Interventions
Initially, the cause for the patient’s respiratory depression was unknown, so a bag-valve mask with high flow supplemental oxygen was placed on the patient for ventilatory support. While the nursing staff was obtaining a fingerstick glucose level, drug paraphernalia was found. The patient was immediately given 0.5 mg of IV naloxone. His GCS and respiratory rate improved slightly. He ultimately received a total of 1.0 mg of naloxone. His GCS improved to 15, and he maintained oxygen saturations above 97% on room air with a normal respiratory rate. The patient admitted to using heroin via his PICC line. An EKG was performed and demonstrated normal sinus rhythm with normal intervals. Due to the patient’s rapid return to baseline after naloxone administration and the patient admitting to heroin use, it was suspected that this was an accidental opioid overdose. The patient remained on the floor with a 1:1 sitter.
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